Volunteer Application Form Page 3
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3.
AUTHORIZATION FOR BACKROUND CHECK
.
ALL INFORMATION MUST BE COMPLETED. PLEASE PRINT LEGIBILITY IN INK
AND SIGN FORM. THIS BACKGROUND CHECK IS ONLY PROCESSED AFTER AN
INTIAL INTERVIEW OR CONDITIONAL OFFER.
Name: ________________________________________________________________
Last
First
Middle
Other Alias or Maiden Name: _______________________________________________
Current Address: ________________________________________________________
Street
City
State/Zip
Previous Address: _______________________________________________________
Street
City
State/Zip
Phone: _______________________
Date of Birth: __________________________
month/day/year
Social Security Number: _______________________________
BACKGROUND INVESTIGATION CONSENT
I, _________________________________________, hereby authorize the Rogue
Valley Family YMCA, and/or its agents to make an independent investigation of my
background, references, character, past employment, education, credit history, criminal or
police records, including those maintained by both public and private organizations and all
public records for the purpose of confirming the information contained on my Application
and/or obtaining other information which may be material to my qualifications for
employment and/or volunteer service now and, if applicable, during the tenure of my
employment and/or volunteer service with the Rogue Valley Family YMCA.
I release the Rogue Valley Family YMCA and/or its agents and any person or entity,
which provides information pursuant to this authorization, from any and all liabilities,
claims or law suits in regards to the information obtained from any and all of the above
referenced sources used.
The following is my true and complete legal name and all information contained herein is
true and correct to the best of my knowledge:
__________________________________________
_______________________
signature of applicant
date
FOR YMCA OFFICE USE ONLY. LEVEL OF SCREENING:
Circle one: 1 (none, youth)
2 (sign waiver) 3 (databases) 4 (on-line)
5 (registry)
Authorized by: _______________________________
Notes: _________________________________________________________________
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